Blood vomiting is defined as the regurgitation of fresh blood and indicates an upper GI bleeding; generally a stomach ulcer, a variceal bleeding or varicose vein underlies ?. Coffee grounds-like vomiting is vomiting of dark brown granular material that resembles coffee grounds. It is caused mostly in infiltration or already stalled bleeding in the upper GIT, the red hemoglobin has been converted by gastric acid in brown hematin.

Gastrointestinal (GI) bleeding can occur and in the GIT from mouth to anus be visible or occult everywhere. The clinical picture depends on the location and extent of bleeding. Blood vomiting is defined as the regurgitation of fresh blood and indicates an upper GI bleeding; generally a stomach ulcer, a variceal bleeding or varicose vein underlies ?. Coffee grounds-like vomiting is vomiting of dark brown granular material that resembles coffee grounds. It is caused mostly in infiltration or already stalled bleeding in the upper GIT, the red hemoglobin has been converted by gastric acid in brown hematin. Under Hematochezia refers to a distinct blood in the rectum. He has generally indicate a lower gastrointestinal bleeding, but can also come from a severe bleeding in the upper GIT, when rapid passage of blood is carried out by the intestine. As melena is called black tarry stool. It typically comes from an upper GI bleeding, but the bleeding source may also be in the small intestine and in the right colon. Approximately 100-200 ml of blood in the upper GIT are necessary to the development of melena that after the bleeding has stopped and, still may persist for several days. Black stools which does not contain occult blood, can occur as a result of absorption of iron, bismuth, or various foods and should not be confused with melena. Chronic occult bleeding can occur anywhere in the GIT and be discovered by chemical testing of a stool sample. Acute, severe bleeding can also occur throughout the GIT. Patients may show signs of shock. Patients with ischemic heart disease can develop through the coronary blood loss stenocardia or myocardial infarction. GI bleeding can lead (kidney failure as a result of liver failure) to portosystemic encephalopathy or hepatorenal syndrome. Etiology There are many possible causes of bleeding (see Table: Common causes of GI bleeding), which are divided into the upper (above ligament of Treitz), that of the lower GIT and the small intestine. Bleeding from any cause occurred more likely and with greater severity in patients with chronic liver diseases (eg. As a result of alcohol abuse or chronic hepatitis) or hereditary bleeding disorders, or in those who are taking certain medications. Drugs that are associated with GI bleeding include anticoagulants (eg. As heparin, Wafarin), those that interfere with platelet function (eg. As aspirin and some other NSAIDs, clopidogrel, SSRI), and those which mucosal defense mechanisms affecting (z. B. NSAIDs). Common causes of GI bleeding Upper GIT duodenal ulcers (20-30%) stomach or Duodenalerosionen (20-30%) varices (15-20%) gastric ulcers (10-20%) Mallory-Weiss tear (5-10%) erosive esophagitis (5-10%) angioma (5-10%) arteriovenous malformations (<5%) Low gastrointestinal stromal GIT (the percentages vary according investigated age group) anal fissures angiodysplasia (vascular ectasia) colitis: radiation, ischemic, infectious colon polyps diverticular inflammatory bowel disease: Colitis / proctitis colitis, Crohn's internal hemorrhoids intestinal lesions (rare) Angioma arteriovenous malformation Meckel's diverticulum tumors clarify the hemodynamic stabilization with airway management, intravenous fluid replacement or transfusions is essential to the diagnostic evaluation before and during. History The history of existing disease should try to check amount and frequency of blood leaving. However, it may be difficult to estimate the quantity, since even small amounts (5-10 ml) of blood color the water opaque red in a toilet bowl and modest amounts of vomit blood an anxious patients appear to be large. However, most between blood streaks know to distinguish a few teaspoons and blood clots. Patients with hematemesis should be asked if the blood was deposed from the start with vomiting or after one (or multiple) bloodless vomiting. Patients with rectal bleeding should be asked whether pure blood was deposed; whether it was mixed with stool, pus or mucus, or if the blood simply clung to the chair or toilet paper. Those with bloody diarrhea should be asked to travel or other potential exposure to pathogens of the gastrointestinal tract. An overview of the symptoms should include the occurrence of abdominal pain, weight loss, easy bleeding or bruising, prior colonoscopy findings and anemia signs (eg. As weakness, easy fatigue, dizziness). The personal history should by previous gastrointestinal ask bleeding (diagnosed or undiagnosed), known inflammatory bowel disease, bleeding and liver disease, as well as by the use of drugs, the likelihood of bleeding or chronic liver disease (eg., Alcohol) erhöhen.Körperliche the general examination investigation focuses on the vital signs and other signs of hypovolemia shock or (z. B. tachycardia, tachypnea, pallor, sweating, oliguria, confusion) and anemia (z. B. pallor, sweating). Patients with less severe bleeding only a slight tachycardia (heart rate> 100) Orthostatic changes in pulse (a change of> 10 beats / min) or blood pressure (a change of ? 10 mmHg) often develop after an acute loss of ? 2 units of blood , However, orthostatic measurements in patients with severe bleeding (which may cause syncope) unwise and usually they lack sensitivity and specificity for the determination of intravascular volume, especially in the elderly. After external features of bleeding disorders (eg. B. petechiae, ecchymoses) is to be sought, as well as for evidence of chronic liver disease (eg. B. spider nevi, ascites, palmar) and portal hypertension (z. B. splenomegaly, dilated abdominal wall veins). A digital rectal examination is necessary for the detection of stool color, lesions and fissures. A anoscopy is performed to diagnose hemorrhoids. The chemical testing a stool sample for occult blood completes the investigation, if there is no discharge of blood occurred ist.Warnhinweise Several findings substantiate the suspicion of hypovolemia or hemorrhagic shock: syncope hypotension pallor sweating tachycardia Clinical Calculator: blood flow to the lower GI tract and risk of serious bleeding interpretation of the findings history and physical examination can diagnose approximately 50% of patients, but the results are seldom diagnostically and must be confirmed by further studies. Epigastric discomfort that can be alleviated by food or antacids can think of a peptic ulcer disease. On the other hand, many patients with bleeding ulcers have no history of pain. Weight loss and loss of appetite with or without a bowel changes indicate a gastrointestinal cancer. The existence of cirrhosis or chronic hepatitis in the history indicates an esophageal varices. Swallowing give an indication of esophageal cancer or stricture. Vomiting and retching before the occurrence of bleeding can think of a Mallory-Weiss tear of the esophagus, although about 50% of patients with Mallory-Weiss tear have no such history. A bleeding history (z. B. purpura, ecchymosis, hematuria) may indicate a bleeding diathesis (e.g., as hemophilia, hepatic failure). Bloody diarrhea, fever, and abdominal symptoms are suspected for the existence of an ischemic colitis, an inflammatory bowel disease (ulcerative colitis, Crohn’s disease) or for an infectious colitis (z. B. Shigella, Salmonella, Campylobacter, amebiasis). A Hematochezia indicates a diverticulosis or angiodysplasia. Fresh blood only on the toilet paper or on the surface of molded chair refers to internal hemorrhoids or fissures, while mixed with the stool blood indicating a more proximal source of bleeding. Fecal occult blood the first sign of colon cancer or a polyp may be, v. a. in patients> 45 years. Nose bleeding can be a source of bleeding in the nasopharynx suspect. Spider nevi, hepatosplenomegaly or ascites are the existence of a chronic liver disease and, accordingly, compatible with esophageal varices. Arteriovenous malformations, v. a. in the mucous membranes, point to hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Telangiectasia in the nail bed and the GIT to an indication of a scleroderma or mixed connective tissue disease sein.Testverfahren Several tests are performed to confirm the diagnosis: total blood count, coagulation status and often other laboratory tests NGS for all patients with minimal rectal bleeding endoscopy for suspected bleeding upper gastrointestinal bleeding colonoscopy in the lower GIT (unless they are clearly caused by hemorrhoids) complete blood counts is required in patients with large volume or occult blood loss. In patients with increased bleeding and coagulation tests (eg. As platelet count, PT, PTT) and provisions of liver function tests (eg. B. bilirubin, alkaline phosphatase, albumin, AST, ALT,) must be performed. Blood typing and cross matching are now required for ongoing bleeding. The determination of hemoglobin and hematocrit should be repeated in patients with severe bleeding about every 6 h. In addition, one or more diagnostic testing methods are usually used. A nasogastric suction flushing treatment via gavage should be performed in all patients suspected of having an upper GI bleed (z. B. hematemesis, coffee-ground-like vomiting, melena, massive rectal bleeding) is. Blood in gastric aspirate indicates active bleeding in the upper GIT, however, show about 10% of patients with upper GI bleeding, no blood in the nasogastric tube. Coffee grounds-like vomiting suggests that the bleeding oozes or has already come to a standstill. If no active signs of bleeding exist, the feeding tube can be removed, otherwise they will be left to monitor an existing or recurrent bleeding. Bloodless, nichtbilliöser reflux is not considered a diagnostic aspirate. An upper endoscopy (examination of the esophagus, stomach and duodenum) is required at the upper GI bleeding. Because endoscopy may be both diagnostically and therapeutically, it should be carried out quickly in case of significant bleeding, but may be postponed h at Come to a halt or minimal bleeding for about the 24th Bariumkontrastdarstellungen the upper GIT play no role in acute bleeding, and the contrast agent used may obscure subsequent attempts to angiography. Angiography is helpful for the diagnosis of upper GI bleeding and allows basically certain therapeutic measures (eg. As embolization or infusion of vasoconstrictors). A sigmoidoscopy or a sigmoidoscope with flexible device may be sufficient in the acute situation in patients with typical symptoms of Hämorrhoidalblutung. For all other patients with hematochezia a colonoscopy is required, the – if not, there is a current circulation – can be electively performed after routine preparation. In such patients, a rapid preparation allowed (5-6 l polyethylene glycol, administered via NGS for 3-4 h) an adequate view in the investigation. If the colonoscopy can not represent the source of bleeding and bleeding a strong current is present (> 0.5-1 ml / min), one can locate with a angiography the source of bleeding. Some Angiographeure initially cause a scintigraphy to narrow the area of ??bleeding because angiography is less sensitive than scintigraphy. The diagnosis of a bleeding source in occult bleeding can be difficult because heme-positive stool bleeding may originate anywhere in the GIT. Endoscopy is the preferred method, wherein the symptomatology determines whether an examination is carried out first in the upper or lower GIT. A double contrast barium or sigmoidoscopy is always performed to investigate the lower GIT when a colonoscopy is not possible or is refused by the patient. If the results of upper endoscopy and colonoscopy not lead to diagnosis and persists occult blood in the stool, a small bowel barium enema, CT Enterographie, a small bowel endoscopy (enteroscopy), capsule endoscopy should (which uses a pill great little camera that is swallowed) a Erythrozytenszintigraphie and angiography are considered. The capsule endoscopy is of limited value in an actively bleeding patients. , Iv therapy airway management if necessary Fluid replacement blood transfusion when required In some cases, angiography or endoscopic hemostasis (See also the American College of Gastroenterology’s practice guidelines on management of the adult patient with acute lower GI bleeding and the practice guidelines on management of patients with ulcer bleeding.) Hematemesis, hematochezia or melena should be considered as an emergency. Recording to an intensive care unit with the assistance of gastroenterologists and surgeons is recommended in all patients with severe GI bleeding. The general treatment is aimed at maintaining a clear airway and circulatory stability. Hemostasis and other treatments depend on the cause of the bleeding. Respiratory A major cause of morbidity and mortality in patients with active upper GI bleeding is the aspiration of blood with the following respiratory impairment. To avoid this problem, should intubation in patients with impaired swallowing reflexes that stunned or dazed, be considered v. a. although in these patients an upper endoscopy performed soll.Flüssigkeitsersatz The intravenous access should be obtained immediately. Short, large-diameter (for example, 14- to 16-gauge) IV catheters are in the antecubital vein over a central venous catheter preferred unless a large (8.5 Fr) sheath is used. Infusions are initiated immediately, as with any patients with hypovolemia or hemorrhagic shock (intravenous fluid replacement). IGesunden adult are administered normal saline in 500 to 1000 mL portions until the signs of hypovolemia have regressed – up to a maximum of 2 liters (in children 20 ml / kg, which may be repeated once). Patients who can not be adequately stabilized in this way, get packed red blood cells transfused. The transfusions are continued until the intravascular volume is restored, then corresponding to the current blood loss. The transfusion in elderly patients or those with coronary heart disease are terminated when the hematocrit at 30% remains stable and the patient is not symptomatic. Younger patients or those with chronic bleeding received no transfusion usually, unless the hematocrit falls below <23 or there are symptoms such as dyspnea or symptoms of coronary ischemia. The platelet count should be closely monitored, a platelet transfusion may be necessary in severe bleeding. Patients who are taking Thrombozytenaggregationsshemmer (z. B. clopidogrel, acetylsalicylic acid), have a platelet dysfunction, which often leads to increased bleeding. Platelet transfusions should be considered if persist in patients taking these drugs, severe ongoing bleeding, although residual amounts of circulating drug (v. A. Clopidogrel) may inactivate transfused platelets. FFP should transfused every 4 units of packed red cells werden.Hämostase GI bleeding suspend spontaneously at about 80% of patients. The remaining patients require intervention. The type of treatment depends on the blood flow localization. Early intervention to control bleeding v. a. important for elderly patients to keep mortality low. In existing peptic ulceration or recurrent bleeding be with endoscopic coagulation (by bipolar electrocoagulation with injection of the sclerosant with thermocoagulation, clips or laser) treated. Not Bleeding vessels that are visible in the ulcer base, are also addressed. If endoscopy does not suspend the circulation, an angiographic embolization of the bleeding vessel can be tried or surgery is required to transfer sew the bleeding site. If the patient has been medically treated for peptic ulcer disease, but has recurrent bleeding, surgeons perform simultaneously Acid reducing operation (Operational procedures). An active variceal bleeding can be supplied with endoscopic banding, sclerotherapy or with a transjugular intrahepatic shunt (TIPS). Severe, continuous, by diverticulum or Angioma-related bleeding of the lower GIT can sometimes colonoscopy by clamping, electrocautery, by coagulation with a thermal probe or by injection of diluted epinephrine be controlled. Polyps may be removed by means of a sling or cauterization. Should these methods be ineffective or impossible angiography with embolization or infusion of vasopressin can lead to success. However, since the collateral blood supply in the intestine is limited, make angiographic techniques represent a significant risk in terms of intestinal ischemia or infarction, unless super selective catheter techniques are used. In most studies, the rate of ischemic complications is <5%. Vasopressin infusions chance is on a hemostasis at about 80%, but it comes at about 50% of patients to recurrent bleeding. In addition, there is a risk of a rise in blood pressure and coronary ischemia. Moreover, the angiography to locate the exact source of bleeding can be used. An operative intervention can with ongoing bleeding in the lower gastrointestinal tract (requiring> 6 transfusion units) may be required in patients; the localization of the bleeding is particularly important in these cases. If the bleeding source can not be located, a subtotal colectomy is recommended. A blind hemicolectomy (without preoperative identification of the source of bleeding) is a much higher mortality risk than a targeted segment resection and does not remove the bleeding site; the rate of recurrent bleeding is 40%. However, the investigation measures must be carried out quickly in order not to unnecessarily delay the surgery. In patients who received> 10 units packed red blood cells, the mortality rate is about 30%. Acute or chronic bleeding as a result of internal hemorrhoids suspend usually spontaneously. Patients with recurrent bleeding are anoskopisch supplied with rubber band ligation, injection, coagulation or surgery. Geriatric Essentials in elderly patients hemorrhoids and colon cancer are the most common causes of minor bleeding. Peptic ulcer disease, diverticular disease and angiodysplasia are the most common causes of severe bleeding. Variceal bleeding is less common than in younger patients. A massive GI bleeding is poorly tolerated by elderly patients. The diagnosis must be made quickly, and the treatment should start earlier than in younger patients better tolerate the repeated bleeding episodes. Important points Rectal bleeding may result from upper or lower GI bleeding. Orthostatic changes in vital signs are unreliable markers for severe bleeding. About 80% of patients the bleeding ceases spontaneously; various endoscopic techniques are usually the first choice for the other cases. For more information (The American College of Gastroenterology’s practice guidelines on management of the adult patient with acute lower GI bleeding.) (The American College of Gastroenterology’s practice guidelines for management of patients with ulcer of bleeding)


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